Prevention of Future Deaths reports · 2018

Jacqueline Valvona

Regulation 28 report to prevent future deaths, reference 2018-0391, written 18 Dec 2018. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report18 Dec 2018
Reference2018-0391
DeceasedJacqueline Valvona
CoronerCaroline Sumeray
Coroner areaIsle of Wight
CategoryRoad (Highways Safety) related deaths
Sourcejudiciary.uk record · original PDF
Responses published2

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

THIS REPORT IS BEING SENT TO: 

1. 

2. 

: Island Roads, St Christopher House, 42 Daish Way, 

Newport, Isle of Wight, PO30 5XJ 

: Isle of Wight Council Highways Department, St Christopher 

House, 42 Daish Way, Newport, Isle of Wight, PO30 5XJ 

1 

CORONER 

I am Caroline Sarah Sumeray, Senior Coroner for the Coroner Area of the Isle of Wight. 

2 

CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 

and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

On 3rd September 2018 I commenced an investigation into the death of Jacqueline 

Françoise  VALVONA,  aged  90.  The  investigation  concluded  at  the  end  of  the 

inquest  on  14th  December  2018.  The  conclusion  of  the  inquest  was  “Road  Traffic 

Collision”. 

The medical cause of death was found to be: 

 1a Multiple Traumatic Injuries 

 1b  

 1c  

  II 

4 

CIRCUMSTANCES OF THE DEATH 

1)  Jacqueline Françoise VALVONA was born on 10th April 1928 in Paris, France. 

At  the  time  of  her  death  she  was  90  years  old.  She  was  a  retired  French 

teacher. She resided at Homebray House, retirement accommodation, which is 

situated midway up the hill in the village of Wootton. 

2)  Mrs  VALVONA  was  an  active  90-year  old  who  endeavoured  to  go  out  at  least 

once a day – often for a meal at the Sloop Inn, or into Newport. Although she 

had  been  diagnosed  with  Vascular  Dementia,  she  was  still  able  to  go  out  and 

1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 about  on  her  own,  although  there  was  some  evidence  that  she  had  suffered 

periods of confusion whilst out previously. 

3)  Up until the last few years, Mrs VALVONA had walked back up the steep hill to 

Homebray House after visiting the Sloop Inn, but latterly she had found it to be 

too difficult to manage, and so she had caught the bus back up the hill from the 

bus-stop opposite the Sloop Inn. 

4)  At approximately 16.23 hours on Thursday 2nd August 2018, 

was  driving  his 

  X1  vehicle,  registration  number 

  along 

the A3054 Wootton High Street in an easterly direction towards Kite Hill. He was 

driving within the speed limit of 30mph. The weather conditions were dry, warm 

and  sunny.  An  elderly  lady  (Mrs  VALVONA)  was  walking  along  the  nearside 

pavement outside the Sloop Inn, she had her back towards the traffic travelling 

in the same direction as she was walking. Several drivers of vehicles travelling 

in the opposite direction had sensed that she might have been about to step out 

into the road to reach the bus-stop on the other side, possibly as they had seen 

her  looking  in  that  direction  a  moment  earlier.  The  sun  was  coming  from  the 

south-west. Due to her eyesight issues, Mrs VALVONA found bright conditions 

to be dazzling and tended to wear a wide-brimmed hat, as she had been on that 

day,  to  reduce  the  glare.  It  is  possible  that  Mrs  VALVONA  had  indicated  her 

intention to cross the road before Mr Hinch’s vehicle was close enough for him 

to see her. 

5)  Mrs VALVONA stepped out into the road without looking to her right before she 

did  so.  This  placed  her  right  in  the  pathway  of  Mr  Hinch’s  vehicle.  He  was 

unable to avoid her. He braked hard before the impact but she struck his vehicle 

and was thrown up onto the bonnet before landing in the road. 

6)  Mrs  VALVONA  suffered  multiple  serious  traumatic  injuries.  One  of  the  drivers 

travelling  in  the  opposite  direction  to  Mr  Hinch  witnessed  the  whole  collision. 

She was an off-duty paramedic. Immediately she went to Mrs VALVONA’s aid. 

An Air Ambulance was requested due to the severity of Mrs VALVONA’s injuries 

and she was airlifted to Southampton General Hospital where she was admitted 

to the General Intensive Care Unit. 

7)  After assessing her, the Clinicians caring for Mrs VALVONA were of the opinion 

that  the  most  appropriate  treatment  for  her  was  palliative  care  as  there  was  a 

poor prognosis and an almost inevitable risk of death from the multiple traumatic 

injuries that she had sustained, although she did have some surgical treatment 

to  reduce  the  risk  of  infection  in  the  open  fracture  in  her  leg.  Mrs  VALVONA’s 

2

 
 
 
 
 
 
 
 family were in agreement with this approach. 

8)  Mrs  VALVONA  died  at  Southampton  General  Hospital  at  13.50  hours  on  20th 

August 2018. 

5 

CORONER’S CONCERNS 

During the course of the inquest the evidence revealed matters giving rise to concern. In 

my opinion there is a risk that future deaths will occur unless action is taken. In the 

circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows:  –  

1. 

I  have  concerns  about  the  lack  of  a  safe  place  for  pedestrians  to  cross  the 

A3054 at that point. There are a great many elderly people who visit the Sloop 

Inn  due  to  the  affordability  of  the  roast meals  there,  and  I  heard evidence  that 

there  are  over  40  elderly  people  living  in  Homebray  House  which  is  a  short 

distance  up  the  steep  hill  that  is  Wootton  High  Street  many  of  whom  enjoy 

visiting this pub/restaurant. 

2.  The  A3054  is  a  busy  single-lane  carriageway  road  with  one  lane  in  each 

direction  taking  much  traffic  from  the  ferry  terminal  at  Fishbourne  to  Newport, 

the  County  town,  and  beyond.  It  is  the  main  link  between  Newport  in  the west 

and  Ryde  on  the  east  of  the  Island  and  this  stretch  of  road  is  predominantly 

residential  in  nature.  Whilst  there  is  a  crossing  higher  up  the  hill  on  Wootton 

High  Road,  if  pedestrians  have  mobility  issues  –  as  Mrs  VALVONA  did  -  they 

are unable to walk up the steep 4° hill incline to reach the crossing. 

3.  There have been 7 slight injury accident in the vicinity in the 5 years leading up 

to 31.12.2017, and I heard evidence that there is a local pressure group which 

has been campaigning for a crossing of some sort to be installed to make this 

popular site for traversing the road to be safer. I also heard that there have been 

a large number of near-miss incidents which don’t feature in the statistics. There 

is an increased tendency for pedestrians to want to cross the road at this point 

as there is a bus-stop opposite the Sloop Inn which stops further up the hill, in 

the middle of Wootton High Street, and thereby means that those with mobility 

issues don’t have to negotiate the hill on foot. 

4.  Whilst the road is almost too narrow at that point to accommodate the inclusion 

of a traffic island (bearing in mind the number of HGVs that traverse that stretch 

of  road),  Senior  Investigating  Officer  Police 

  said  in 

evidence  that  he  would  support  the  proposition  that  either  a  pelican  or  zebra 

3

 
 
 
 
 
 
 
 
 
 crossing be installed at this point to prevent future deaths as it would mean that 

the traffic has to stop to allow pedestrians to get across safely. 

6 

ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you and/or 
your organisation have the power to take such action.  

7 

YOUR RESPONSE 

You are under a duty to respond to this report within 56 days of the date of this report, 
namely by 12th February 2019. I, the Coroner, may extend the period. 

Your response must contain details of action taken or proposed to be taken, setting out 
the timetable for action. Otherwise you must explain why no action is proposed. 

8 

COPIES and PUBLICATION 

I  have  sent  a  copy  of  my  report  to  the  Chief  Coroner  and  to  the  following  Interested 
Persons: 

I am also under a duty to send the Chief Coroner a copy of your response.  

The  Chief  Coroner  may  publish  either  or  both  in  a  complete  or  redacted  or  summary 
form. He may send a copy of this report to any person who he believes may find it useful 
or  of  interest.  You  may  make  representations  to  me,  the  Coroner,  at  the  time  of  your 
response, about the release or the publication of your response by the Chief Coroner. 

9 

H.M. Senior Coroner – Isle of Wight 

18th December 2018 

4

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from Island Roads (PDF)
Island Roads 
St. Christopher House, 
42 Daish Way, Newport, 
Isle of Wight, PO30 5XJ 
Tel: 01983 822440 
www.islandroads.com 

Caroline Sumeray 
H.M. Senior Coroner for the Isle of Wight 
Coroner’s Office 
Seaclose Offices 
Fairlee Road 
Newport 
Isle of Wight  
PO30 2QS 

11th February 2019 

Dear Ms Sumeray 

Subject: Response to Regulation 28 report regarding the death of Mrs Valvona. 

Ringway Island Roads as Highway Service Provider has reviewed the contents of the 
Regulation 28 Notice received from the Coroner during late December 2018, in which 
concerns were expressed in regard to the lack of safe places to cross the A3054 at the 
place that the collision occurred.  

Having  reviewed  recent  collision  data,  the  volume  of  vehicles  using  the  road,  the 
number of pedestrians crossing the road at the point that the collision occurred and 
availability of alternative crossing facilities, the following response is provided.   

Crossings  are  provided  as  amenities  to  give  access  and  easier  movement  to 
pedestrians. Generally, the provision of crossings should be targeted at the needs of 
those people who experience most difficulty and danger.  

The assessment therefore takes into account the number, age and mobility need of 
pedestrians crossing in the area. 

Site description 

The A3054 through Wootton is the main link between Newport and Ryde, carrying in 
the  region  of  17,000  vehicles  per  day.  During  peak  times,  the  two-way  flow  is 
approximately 1,200 vehicles per hour. 

The  location  of  the  collision  was  outside  the  Sloop  Public  House  at  a  central  point 
between the western and eastern access points to Mill Square. The footway on the 
north side of the carriageway terminates at the western boundary to Wootton bridge. 
No through access for pedestrians is available on the north side of the carriageway, 
with the only continuous access between Wootton and Fishbourne on the south side 
of the road. 

The distance between Station Road and Firestone Copse Road is 1km.  In this length 
of road there are three controlled pedestrian facilities and two pedestrian refuges. The 

Ringway Island Roads Ltd 
Registered Office: Albion House, Springfield Road, Horsham, West Sussex RH12 2RW     Registered in England No: 8108944    VAT Registered No. 321 9318 74 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 nearest controlled facility to Mill Square is 180m to the west.  A pedestrian refuge is 
also provided approximately 170m to the east. 

In  2016  a  traffic  count  was  carried  out  approximately  150m  east  of  the  proposed 
crossing  point.    This  showed  85th  percentile  speeds  of  29mph.    This  indicates  that 
most drivers comply with the 30mph speed limit. 

Collision history from the east of the junction with New Road and the western 
boundary of Wootton Bridge  

The last five years (1st November 2013 to 31st October 2018) of collision data has been 
reviewed  and  the  collision  involving  Mrs  Valvona  was  the  only  pedestrian  collision 
during this period.  The other collisions that have occurred involved; 

  One rear end shunt at temporary traffic lights 
  One loss of control in icy conditions 
  One mechanical failure (part of trailer breaking away) 
  One poor turn out of Mill Square in to vehicle travelling east 

Action taken 

Following  receipt  of  the  Coroner’s  report,  a  review  of  the  site  and  the  suitability  of 
installing a controlled crossing facility, has been undertaken.  The site has therefore 
been reviewed using the guidance contained within Local Transport Note 1/95.   

Island  Roads  have  been  instructed  by  the  Isle  of  Wight  Council  to  undertake  a 
feasibility  design for  a controlled  crossing  and  a  concept  layout  has  been  drawn  up 
and costed. 

This feasibility design process has established that due to the approach alignment, the 
location of junctions and the bus layby, the only location where a crossing could be 
accommodated is between the two bus stops.  However, during the survey it was noted 
that most pedestrians crossed close to the Lakeside Hotel access, some 45m away 
from  the  location  of  any  controlled  crossing.    The  proposed  crossing  point  would 
therefore not be on the pedestrian desire line and is unlikely to be used by able bodied 
persons.  

The  assessment  also  involved  undertaking  a  pedestrian  survey  to  determine  the 
demand, and difficulty crossing during peak periods.  

Although not the only measure of determining where a pedestrian crossing would be 
of benefit, PV squared is a useful calculation to compare the pedestrian/vehicle conflict 
at  different  sites.    At  this  location,  the  value  calculated  indicated  that  the  level  of 
pedestrian  demand  is  well  below  where  a  controlled  pedestrian  crossing  would 
normally  be  considered.  Adjustments  can  be  made 
into  account 
unaccompanied children, elderly and mobility impaired pedestrians, but this is unlikely 
on its own to substantiate the justification for a controlled crossing facility. During the 
survey  undertaken  on  20th  January  2019,  no  children  were  observed  and  4%  of 
pedestrians had some form of mobility impairment. 

take 

to 

Ringway Island Roads Ltd 
Registered Office: Albion House, Springfield Road, Horsham, West Sussex RH12 2RW     Registered in England No: 8108944    VAT Registered No. 321 9318 74 

 
 
 
 
 
 The survey considered the difficulty crossing and observed that generally, able bodied 
pedestrians crossed the road in less than 6 seconds and waited less than 20 seconds 
for a suitable gap in which to cross. 

The one observed mobility impaired pedestrian took 8 seconds to cross and had to 
wait for 1 minute for a gap to do so. 

Visibility at the site is good and pedestrians without any obvious mobility impairments 
did not have to wait long for a suitable gap to cross safely. 

Whilst LTN 1/95 provides wider advice on the installation of new controlled crossing 
facilities,  there  are  a  number  of  points  that  appear  to  relate  specifically  to  the 
installation of a controlled crossing at the location in question. They are; 

4.2.4 - Caution should be exercised where pedestrian flows are generally light or light 
for long periods of the day. Drivers who become accustomed to not being stopped at 
the  crossing  may  begin  to  ignore  its  existence,  with  dangerous  consequences.  The 
problems are accentuated as vehicle speeds increase. 

5.1 - The final decision as to whether to install a crossing and the choice of option will 
depend on a combination of factors. Examples are: the number of accidents, delays, 
local representations, local interest groups, cost and relative priority with other sites. 

5.2  -  The  use  of  a  formal  cost  benefit  methodology  is  not  thought  necessarily 
appropriate  to  the  assessment  of  individual  crossings.  The  costs  of  delays  to  road 
users are generally not reduced by the introduction of a pedestrian crossing. Neither 
can the road safety benefits be quantified with any degree of certainty and it should 
not be assumed that provision of a crossing will necessarily lead to a reduction in road 
accidents. 

Action to be taken 

As each of the main trip generators in the area are likely to experience a significant 
seasonal  variation,  a  further  pedestrian  survey  will  be  undertaken  in  the  summer 
months  to  determine  the  vehicle  and  pedestrian  numbers  during  the  peak  tourist 
season.  

On  receipt  of  the  summer  month  peak  flow  data,  a  further  assessment  will  be 
undertaken such that the suitability of a new controlled crossing and the potential for 
funding can be finalised. 

Yours sincerely 

Service Director – Ringway Island Roads 

Ringway Island Roads Ltd 
Registered Office: Albion House, Springfield Road, Horsham, West Sussex RH12 2RW     Registered in England No: 8108944    VAT Registered No. 321 9318 74
Response from Isle of Wight Council (PDF)
From 

Interim Strategic Manager – Highways & 
Transportation 
Highways PFI Contract Management Team 
St Christopher House 
42 Daish Way 
Newport 
Isle of Wight 
PO30 5XJ 

(01983) 821000 x 6610 

Tel 
Email 
DX 
Web  www.iwight.com 

56361 Newport (Isle of Wight) 

To 
Caroline Sumeray 
H.M. Senior Coroner for the Isle of Wight 
Coroner’s Office 
Seaclose Offices 
Fairlee Road 
Newport 
Isle of Wight  
PO30 2QS 

11th February 2019 

Dear Ms Sumeray 

JACQUELINE VALVONA 

I refer to your Regulation 28 Report dated 18th December 2018.  I am aware that you also wrote to 
Island Roads, who are the Isle of Wight Council’s Highways PFI Service Provider and that they will 
respond to you separately. 

Following the death of Jacqueline Valvona, Island Roads and the Police undertook a joint visit to 
determine whether there were any deficiencies in the highway layout which may have contributed 
to the accident.  They found nothing which could have been considered a contributory factor to the 
accident. 

Your report also makes reference to the comment by Police Sergeant Morgan who stated that he 
would  support  the  proposition  that  a  pedestrian  controlled  crossing  be  installed  to  prevent  future 
deaths.    Whilst  this  would  reduce  the  likelihood  of  future  accidents,  deaths  can  still  occur  at 
pedestrian crossings when motorists fail to stop. 

Following  receipt  of  your  report,  a  review  of  the  site  and  the  suitability  of  installing  a  controlled 
crossing facility was undertaken by Island Roads on behalf of the Council.  The site has therefore 
been reviewed using the guidance contained within Local Transport Note 1/95. 

The Isle of Wight Council instructed Island Roads to undertake a feasibility study and design for a 
pedestrian controlled crossing at this location.  The process established that due to road alignment, 
nearby junctions and bus lay-by that the only location where a crossing could be accommodated is 
between the two bus stops.  During the feasibility design stage Island Roads observed the area to 
assess  the  level  of  demand  for  a  new  pedestrian  crossing,  and  found  that  pedestrian  numbers 
were well below that where a crossing would be considered.  However, the process also identified 
that most pedestrians crossed close to the Lakeside Hotel access road, and therefore it is probable 
that the proposed crossing point is unlikely to be used by able bodied persons. 

Visibility at the site is good and pedestrians without any obvious mobility impairments did not have 
to wait long for a suitable gap to cross safely. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2 

At  the  current  time  the  evidence  held  by  the  Council  does  not  indicate  that  the  site  meets  the 
criteria  to  consider  a  pedestrian  controlled  crossing  but  I  am  aware  that  the  area  is  likely  to 
experience seasonal variation.  Therefore the Council would propose that Island Roads undertakes 
a  further  assessment  in  the  summer  to  determine  whether  the  vehicle  and  pedestrian  numbers 
indicate that the site should be considered for a new crossing. 

Yours sincerely 

INTERIM STRATEGIC MANAGER – HIGHWAYS & TRANSPORTATION

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